Demystifying Medicine One Week at a Time

The recently signed health care reform bill was passed through a process called reconciliation. This was a bit controversial politically, because the unified Republican opposition wanted to prevent the bill from becoming law. In this context, reconciliation meant negotiating a compromise to the House and the Senate versions of the bill through budget negotiations to achieve implementation of the law.

Medication reconciliation is altogether different, in that there’s no controversy. We ALL need to be doing it, according to JCAHO (the Joint Commission on Accreditation of HealthCare Organizations, pronounced “Jay-co”) the IHI (Institute for HealthCare Improvement, brainchild of Dr. Donald Berwick, recently appointed-but-as-yet-unconfirmed head of CMS, the government’s Medicare and Medicaid entity), and virtually every other person and organization involved in improving the quality and safety of health care for patients.

Reconciling medication seems too basic to even think about, but it’s a much more complex task than it appears at first glance.

What is it?

When a patient, let’s say for example someone named “Nancy,” is admitted to the hospital, there’s a pretty good likelihood that she’s already taking some daily medications for one or more chronic conditions. Think of a top five that might spring to mind:

High blood pressure (“hypertension”)

Diabetes

Heart Disease

Reflux (“GERD”)

Osteoporosis

Each of these conditions are common in the general population (you or someone you know has at least one), and are usually managed with at least some medication in pill form. Of course, individuals and the medications they’re on will vary.

And that’s precisely the point.

Let’s say “Nancy” is 65 or older. If so, she’s likely on three daily prescription medications, and if she’s older or has more than one of these conditions, the number of daily pills can easily rise to double digits.

She comes to the hospital. She’s interviewed and examined by a nurse; then by a doctor (or three, depending on whether the hospital in question is a teaching hospital or not).

“What medications do you take?” Nancy is asked not one but two or more times.

Does she provide a list or printout of her medications? Does she recall them by name and dosage? Or does she, like millions of Americans, say “I take the blue one for my blood pressure and the pink one for my reflux.”

This may surprise you, but doctors have NO IDEA what the pills we prescribe look like. Telling us the pill color or pill size is a surefire recipe for at least misunderstanding and at worst disaster (as in we give Nancy the wrong pill, or omit the correct one, leading to harm).

Let’s hope Nancy carried her pill bottles with her, a smart move because then they can be catalogued, in addition to knowing what pharmacy she fills them at. Usually a good idea to call the pharmacy to verify.

Now we’re getting somewhere. The nurse jots down the medication names and doses on his admission form (Nancy has “Dave” as her admission nurse). The intern (a doctor in her first year of training out of medical school) asks what medications Nancy is on, but Nancy tells Dr. Newbie that she’s already answered that question and to “look at what the nurse wrote down.”

Dr. Newbie will likely look at Dave the nurse’s admission form, but if she’s busy with a lot of hospital admissions that night, she might not. If she’s very thorough, she will call the retail pharmacy to verify medications and doses.

You can see where this might start to break down. And this is only the admission.

Each drug has to be evaluated in the context of the reason that Nancy has been admitted. If she’s on metformin for her diabetes, then should she stay on the pill in the hospital or not? We certainly don’t want her diabetes to get out of control while she’s in our hospital, do we?

Nancy was admitted for pneumonia. In addition to some of her “home meds,” (as we call them) she gets started on the hospital’s “antibiotic du jour,” i.e. a go-to drug that we commonly use for common conditions. It so happens that at GlassHospital, like all hospitals, we get bulk discounts on some drugs and told that they’re “formulary preferred.” The problem with this will come later.

Let’s say that all goes well, and Nancy’s pneumonia starts to get better. It’s now approaching discharge time.

Do the doctors reflexively put her back on all of her home medications? This is straightforward for the drugs that she came in on and has continued all along. But what about her heart medicine that was stopped since it lowers blood pressure and the pneumonia itself had caused Nancy’s blood pressure to transiently drop? Do we re-start it right away? Do we wait for her primary care doctor or cardiologist to issue the instruction?

And what about the antibiotics? The hospital’s contract with the newer, more expensive respiratory flouroquinolone (a group of newer and well-tolerated antibiotics that have the advantage of being able to be given only once per day) only covers the medicine while Nancy’s in the hospital.

Makes sense to keep her on the antibiotic she’s on, right? After all, she’s been getting better on it.

But her pharmacy plan does not prefer that drug. In fact, a mere seven days of that one type of pill costs more than one hundred dollars retail!

Time out! Who’s keeping track of all of this? And how? Is it done with a computerized record, or are we relying on the old-fashioned pharmacy printouts (“MAR”= Medication Administration Record)?

Solution: let’s put Nancy on a generic antibiotic, that will work as well as the costly one, and only cost a fraction. Let’s give her clear written instructions about which pills she will take at home, and which of those she came in on that have been discontinued.

The doctors and the nurses need to cooperate, and most importantly, communicate about all of this. Let’s hope that in addition to giving Nancy her discharge papers, on which this is all spelled out so clearly that an eighth-grader would understand it, her family is included in the education and discharge process.

And since she’s returning to the “outpatient” world, let’s hope GlassHospital has a mechanism for transmitting all of this new information to her Primary Care Doctor.

7 Comments

We have made great progess in the medication reconciliation crap shoot. Years ago, physicians had no clue what patients were on when they were admitted, and patients had no idea what they were supposed to be taking after they were discharged. Best of luck with your blog. http://www.MDWhistleblower.blogspot.com

Thanks for your comment. Agree that we’ve come a long way. Is it the new requirements that have helped get us there, or an overall sense that we’ve been flailing away without much success for such a long time?

I don’t recall how I came across your blog but I added it to the aggregator a couple of weeks ago.
I’m just an old guy blogging in retirement and have been doing my homework about health care reform for the last couple years or more. Looks to me like you’re providing a valuable service making what you do understandable to non-medical people. Keep up the good work.

“Let’s hope Nancy carried her pill bottles with her, a smart move because then they can be catalogued, in addition to knowing what pharmacy she fills them at.”

When I checked in the hospital (for my first time ever), I brought all my prescription, and even non-prescription, bottles with me in a transparent plastic bag, not to mention the list of them that I keep in my wallet. The intake guy seemed pleased as he copied the information. Someone took the bag. (I understood why they’d not want me to have them with me in my room during my stay.)

When I finally checked out after recovery, I asked for my bottles (which had contained, I estimated, about $200 worth of pills). They didn’t know anything about them.

A few days later, I went back and asked what the normal procedure should have been. It was: after listing them among my possessions on the Patient Possessions form, they’d have turned them over to the in-hospital pharmacist for safekeeping. So, I went to Medical Records and asked to see my file. The Patient Possessions form was completely blank, aside from my name and case number.

Next time I check in for a non-emergency, if ever, I’ll take all the bottles again — but beforehand I’ll have carefully emptied each one into its own separate clearly labeled plastic bag at home first, and left the pills there.

“What medications do you take?” Nancy is asked not one but two or more times… …The nurse jots down the medication names and doses on his admission form

Ah, maybe in an ideal world, but that’s not what I experienced. I have my meds list listed on the notes page of my cell phone, in case there ever was an emergency. When that emergency occured, the medic walked away when I tried to give him my phone so he could copy the meds list (correctly spelled, dosage, etc). It was left in the wreckage on the side of the road. Ultimately I spelled all my meds for three different medics, who all appeared to be writing them down. Then at the hospital those lists all disappeared and I spelled my meds for whoever brought the cart-on-wheels, but that person couldn’t find some of my meds on her computerized list, wasn’t able/willing to just write them down and get help from someone else, so gave up and said that my nurse would ask for my meds list. The nurse assumed that since there was information in the computer, it was accurate. I was not in any condition to follow up and provide my meds list after that time. Not until discharge, when I was told to take ibuprofen did I discover the problem. Um, no. Two NSAIDS are usually considered a bad idea. What if I hadn’t known that? What if it had been a significantly more serious problem.

Carrying a printed list in my purse and having a backup list on the cell phone in my pocket turned out to be meaningless when people wouldn’t listen to me or share information with one another.

I can certainly understand your frustration, but as a former Paramedic, I would like to offer another perspective.

On a trauma call, the standard of care for EMS is ten minutes on the scene. This means that from the time the ambulance arrives, the goal is to assess the scene, assess the patient, extricate the patient if necessary, perform any necessary emergent procedures, package the patient, load the patient, and get en route to the hospital within 10 minutes. While the medic does need to know what medications the patient is taking, she usually does not have time to write a complete list of meds, their dosages, the pharmacy, and the prescribing doctor(s). En route, the medic may or may not have time to do so; much depends on transport time to the hospital and the level of care required by the patient.

Many EMS services also limit the time that the crew is allowed at the hospital to 20 minutes from arrival; during that time, the patient must be unloaded and settled in the ER, reports must be given to the receiving providers, the written report must be completed and submitted, and the ambulance sanitized and cleaned.

You must realize that in the hospital, there is an entire staff (nurses, doctors, aides, and clerical personnel) to do the same job that the medic is doing by herself while bouncing down the road.That said, the medic should have been careful to guard the information and ensured that the cell phone arrived at the hospital with you.